DRG Optimization and Case Mix Index Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 DRG Optimization and Case Mix Index flashcards as text
A hospital's case mix index (CMI) dropped from 1.85 to 1.72 over one quarter despite stable patient volume. Which action is MOST likely to identify the root cause?
Answer: Audit high-weight DRGs for documentation completeness and CC/MCC capture rates
Auditing CC/MCC capture rates in high-weight DRGs directly identifies documentation gaps that reduce CMI.
Which physician documentation practice most directly prevents DRG optimization in the inpatient setting?
Answer: Documenting only the chief complaint without linking complications
Failing to link complications to underlying conditions prevents coders from assigning CC/MCC codes that affect DRG weight.
Under MS-DRG logic, a patient admitted for pneumonia with documentation of sepsis due to pneumonia would most likely be grouped to which category compared to pneumonia alone?
Answer: A higher-weighted DRG because sepsis functions as an MCC
Sepsis documented as a complication of pneumonia qualifies as an MCC, shifting the case to a higher-weighted MS-DRG.
A CDI specialist queries a physician about a patient with a BMI of 42, hypertension, and type 2 diabetes who underwent CABG. What is the PRIMARY optimization opportunity?
Answer: Documenting morbid obesity as a secondary diagnosis to capture the CC/MCC impact
Morbid obesity (BMI ≥40) is an MCC that, when documented, can significantly increase the DRG weight for cardiac surgery cases.
When comparing a hospital's CMI to peer institutions, which factor must be controlled to ensure a valid comparison?
Answer: Payer mix, teaching status, and service line distribution
Payer mix, teaching status, and service line distribution all directly influence CMI independently of documentation quality.
A coder assigns acute respiratory failure as an MCC for a COPD exacerbation case. The physician's note states 'patient required supplemental oxygen; respiratory status improved.' What is the MOST appropriate next step?
Answer: Query the physician to clarify whether acute respiratory failure is clinically supported and should be documented
Supplemental oxygen use alone does not clinically establish acute respiratory failure; a physician query is required to confirm or refute the diagnosis.
Which metric best reflects the financial impact of a CDI program's DRG optimization efforts over time?
Answer: Facility-adjusted expected CMI versus actual CMI trend
Tracking actual CMI against facility-adjusted expected CMI isolates the documentation-driven component of case weight improvement.